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Understanding health insurance issues and their effect on benefits

Accessing the full benefits a patient is entitled to under his or her health plan contract requires understanding a few things about all the factors that affect access to care and reimbursement. Navigating the system to find out what the patient is entitled to receive also takes a lot of energy and most patients entering treatment will not have the energy to see it through and need someone to take this on, on their behalf. The information in this section is intended to provide the background needed to navigate the system as effectively as possible. This information reflects the experience of many patients, their families, and treatment centers in obtaining benefits to cover the cost of treatment of bulimia nervosa.

Because treatment usually involves both mental healthcare and medical care aspects, a well-rounded care plan must address both types of care. The overall healthcare system has long treated medical care and mental healthcare separately. The result of that care model is that health insurers' benefits plans have often followed suit by separating mental health benefits (also called behavioral health benefits) from medical benefits. This split has created great difficulty for people with bulimia nervosa who need an integrated care plan. Ways to steer through these difficulties are offered here in a 7-step plan and checklist.

Another issue is the level of benefits for mental healthcare. For years, many health plans provided few or no mental health benefits. When they did, most subcontracted those benefits through "mental health carve-out" plans. Such plans are administered by behavioral health service companies that are separate from health plans. This approach made well-rounded care by a multidisciplinary care team very difficult to achieve. Even when a psychotherapist and medical doctor recognize the need for integrating services and case management, the healthcare delivery system may pose barriers that prevent that from happening.

When a service is provided by a doctor or facility, a billing code is needed to obtain reimbursement for services. Certain regulations govern how services must be coded. Different types of facilities and different healthcare professionals must use codes that apply to that type of facility and health professional. Also, if codes don't exist for certain services delivered in a particular setting, then facilities and health professionals have no way to bill for their services. Codes used for billing purposes are set up by various entities, such as the American Medical Association, U.S. Medicare program, and the World Health Organization's International Classification of Diseases. Thus, even a patient with good health insurance may face barriers to care simply because of the way our healthcare system is set up.

The system is slowly changing. Sporadic improvements have come about as a result of lawsuits and state legislation prompted by individuals, legislators, clinicians, support groups, and mental health advocacy groups. The U.S. federal government and most U.S. states have passed some form of mental health parity law. Generally these laws require insurers to provide a level of benefits for mental healthcare that is equivalent to medical benefits. These laws do, however, vary widely in their provisions. You can find out about the mental health parity laws in your state in the map provided here.

Landmark lawsuits brought by families of patients with bulimia nervosa and/or anorexia in two states, Wisconsin in 1991, and Minnesota in 2001, were watershed events that set legal precedents about what insurers should cover for eating disorders. These lawsuits also raised public awareness of the problems faced by people seeking coverage for treatment of eating disorders. Nonetheless, the system today has a long way to go to improve access to care and adequate reimbursement for care for a sufficient period of time for a patient with bulimia nervosa.

Given that appropriate well-integrated treatment for bulimia nervosa can easily cost more than $30,000 dollars per month, even with insurance, an insured individual is usually responsible for some portion of those costs.

The first-line of decision making about benefits at a health plan is typically made by a utilization review manager or case manager who reviews the requests for benefits submitted by a healthcare provider and determines whether the patient is entitled to benefits under the patient's contract. These decision makers may have no particular expertise in the complex inter-related medical/mental healthcare needs for bulimia nervosa. Claims can be rejected outright or approved for only part of the recommended treatment plan. Advance, adequate preparation on the part of the patient or the patients' support people is the best way to maximize benefits. Prepare to be persistent, assertive, and rational in explaining the situation and care needs. Early preparation can avert future coverage problems and situations that leave the patient holding the lion's share of bills.

Seven steps to maximize insurance benefits

  1. Get organized.
    If a bulimia patient's first encounter with the healthcare system is admission to an emergency room for a life-threatening situation with bulimia nervosa, whoever is going to deal with insurance issues on the patient's behalf will need to organize more quickly to figure out how to best access benefits. Patients who are seriously medically compromised will likely be in the hospital for a few days before discharge to a residential eating disorder center. Those few days are critical to negotiating reimbursement for the longer-term care. If the situation is not an acute emergency and you want to find a treatment center, figure out whether you have authority to act on the patient's behalf or whether the patient must give you written authority to act on his/her behalf. If a child is 18 or older, parents will need the child's written permission to act on the child's behalf. Healthcare providers have forms that require signatures to allow free flow of communication and decision making. A spouse, partner, friend, or other person who wants to act on behalf of the patient will need to have the patient sign appropriate authorizations. Medical confidentiality is discussed later in this section.

  2. Read the patient's insurance policy carefully to understand the available benefits.
    Obtain a copy of the "summary plan description" from the health plan's member's Web site (i.e., the specific plan that pertains to the insured), the insurer or, if the insurance plan is through work, from the employer's human resources department. Do not rely on general pamphlets or policy highlights. Read the detailed description of the benefits contract to find out what is covered and for how long. If you can't understand the information, try talking with the human resources staff at the company that the insurance policy comes through, with an insurance plan representative, or with a billing/claims staff person where treatment will be sought. If hospital emergency care is not needed, make an appointment with a physician you trust to get a referral or directly contact an eating disorder treatment center to find out how to get a full assessment and diagnosis. The assessment should consider all related physical and psychological problems. There are 4 main reasons for doing this:
    • To obtain as complete a picture as possible about everything that is wrong;
    • To develop the best plan for treatment;
    • To obtain cost estimates before starting treatment;
    • To obtain the benefits the patient is entitled to under his or her contract for the type of care needed—for example, many insurers provide more coverage benefits for severe mental disorder diagnoses. Some insurers categorize bulimia nervosa as a severe disorder that qualifies for extensive inpatient and outpatient benefits, while others may not.
    Medical benefits coverage may also come into play to treat bulimia nervosa-associated medical conditions, so it is important to diagnose all physical illnesses present. Other mental conditions often co-exist with underlie bulimia nervosa and should be considered during the assessment, including depression, trauma, obsessive-compulsive disorder, anxiety, social phobias, and chemical dependence. These co-morbid conditions can affect eligibility for various benefits (and often can mean more benefits can be accessed) and eligibility for treatment centers.

  3. Keep careful and complete records of communications with the insurance company and healthcare providers for future reference as needed.
    Treatment for bulimia nervosa often occurs over a long period of time. Maintaining a log book—whether computerized or in hard copy—can be important for future reference if there are questions about claims. Decide where all notes and documentation will be kept for easy access. Create a back-up copy of everything, and keep it in a safe and separate place. The log should contain notes taken of each conversation with an insurer or healthcare provider and should include the date, time, name and title of person with whom you spoke, and their contact information. As a courtesy, you may wish to let these people know that you are keeping careful records of your conversations to help you and the patient remember what was discussed. If you decide to record any conversation, you must first inform and ask the permission of the person with whom you are speaking.

  4. Call the insurer to discuss benefits options.
    With documentation in hand of the patient's diagnosis and the proposed care plan, it's a good idea to call the patient's insurance company before the patient enters a treatment program. Quite often, preauthorization for a treatment faclilty or healthcare provider is needed. Ask for a case manager who has credentials in eating disorders. This will improve your chance of getting one contact person to talk with over the longer term of treatment who understands the complexities of treatment. Confirm with the insurer that the patient has benefits for bulimia nervosa treatment. Also ask about "in-network" and "out-of-network" benefits and the eating disorder facilities that have contracts with the patient's insurance company because this affects how much of the costs the patient is responsible for. If the insurer has no contract with certain treatment facilities, benefits may still be available, but may be considered out-of-network. In this case, the claims will be paid at a lower rate and the patient will have a larger share of the bill.

    If the health insurance is through an employer and the patient had to quit work or take a leave of absence to get treatment, s/he may no longer be covered. Similarly, if the patient is a college student who had to drop out of school to seek treatment and was covered by school insurance or a parent's insurance policy, the student may no longer be covered. While many people with bulimia nervosa continue working or attending school, some cannot. If this is the case, it's important to understand what happens with insurance. Most insurance policies cover students as long as they are enrolled in 12 credit hours per semester and attend classes. Experts in handling insurance issues for patients with eating disorders caution that patients who have dropped out of school should avoid trying to cover up that fact to maintain benefits because insurance companies will usually find out and then expect the patient to repay any benefits that were paid out.

    If coverage has been lost, the student may be eligible to enroll in a COBRA insurance program. COBRA is an Act of Congress that allows people who have lost insurance benefits to continue those benefits as long as they pay the full premium and qualify for the program. See www.cobrainsurance.com for more information. A person eligible for COBRA has only 30 days from the time of loss of benefits to enroll in a COBRA plan. It is critical that the sign up for COBRA be done or that option is lost. Be sure to get written confirmation of COBRA enrolment from the plan. If the student is not eligible for COBRA, an insurance company may offer a "conversion" plan for individual coverage.

    If the patient is in the hospital and will be discharged to a residential treatment center, discuss how the medical and behavioral health components of benefits will work. Although a patient may be "medically stable" at discharge, s/he may not be nearly well enough to participate fully in psychotherapy at the residential center. The patient's medical condition, though not life-threatening at this point, affects mental health and ability to participate in treatment. Restoring physical health may take days or weeks. Therefore, before the patient is admitted to a residential eating disorder center or placed in outpatient treatment, contact the patient's health plan or employer (if applicable and the health plan is self-funded by the employer) and ask for the early claims for psychotherapy to be paid under the medical benefits instead of the behavioral health benefits. The language to use is: "Will you intercept psychotherapy claims and pay them under medical benefits until the patient is stable enough to participate fully and assist in her treatment?" Not all health plans will do this, but some do, so it's worth asking. Going this route can save the behavioral health benefits for the time when the patient is better able to take part in the psychotherapy.

    Another way to get the most out of benefits is to find out whether chemical dependency or substance abuse benefits are included in the mental health day allotment or if it is a separate benefit. If it is separate and the patient does not really need this benefit, find out whether the insurer will "flex" the benefit to apply it for treating an eating disorder.

  5. Find out the authorizations for care that the insurer requires for the patient to access
    care. Once insurance benefits are confirmed, be sure to obtain the health plan authorizations required for reimbursement for the care the patient will receive. Sometimes authorizations and referrals are sent electronically to the concerned parties. Always confirm that they have been sent and received by the appropriate parties. Ask for the level-of-care criteria the patient must meet to be eligible for the various levels of benefits. Again, keep a record of the authorizations received.

  6. Communicate with key caregivers to give any needed input and devise a treatment plan.
    Obtain the names of the people who will be providing care and have daily interactions with the patient (including lower level staff such as aides). Try to meet with or talk by phone to each caregiver on the team. Discuss the diagnosis (and whether there is more than one primary diagnosis), treatment options, and ask whether there is clinical evidence to support the recommended treatment and what that evidence is. This information can be useful when talking to the insurance company about benefits because insurance companies value evidence-based care. Also ask how the treatment plan will be coordinated and managed, and who will do the coordination. People with bulimia nervosa often have close to normal body weights. However, serious, but less obvious medical conditions may also be present. These conditions include: osteoporosis, heart problems, kidney problems, brain abnormalities, diarrhea, reflux, nausea, malnutrition, and heartburn. Tests that are used to diagnose medical symptoms and criteria for levels of care are listed in this guide. Ask for "letters of support" from the healthcare team. These letters should describe the treatment plan and reference the available evidence to support the treatment choice (such as an evidence report or evidence-based clinical practice guidelines). The letter should also include the rationale for each level of care, anticipated duration of care, the treatment center or setting in which care will be delivered. It is useful to use language that is used by insurance companies to have common ground. For example, it's important to point out care that is considered by the doctors to be "medically necessary" for the patient's recovery. Documentation like this is useful to provide to the insurer when discussing reimbursement because it gives both you and the insurer a framework to discuss. With regard to the healthcare providers, ask them how to and who can obtain copies of the patient's medical records, who will provide progress reports, how often and to whom Ask the healthcare provider (whether it's a facility or an individual therapist) for an itemization of the estimated costs of care, which costs will likely be paid by the insurer and which by the patient. Also ask how billing for reimbursement will be handled—ask whether you have to submit claims or whether the healthcare service provider submits the claims on the patient's behalf.

  7. Enlist support from family members and friends you can count on.
    Make a list of people you can count on for moral support throughout the course of treatment. Keep their names, phone numbers, and email addresses handy. For this list, identify people who can help the patient remain focused and provide helpful emotional support and encouragement while navigating the system to obtain care and while receiving care. Find out from each of them their availability (times, dates) for support and the kind of support they can offer. Also consider distributing that list among key people on the list so they know who is in your support network. Also, list key healthcare provider (facilities and healthcare providers) contact numbers on that list in the event of an emergency.

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Bulimia nervosa is an eating disorder in which a person engages in binge eating (eating a lot of food in a short time) followed by some type of behavior to prevent weight gain from the food that was eaten. This behavior can take two forms: self-induced vomiting, misuse of enemas, laxatives, diet pills (called purging) and excessive exercise, fasting, or diabetic omission of insulin (called non-purging). Some people with bulimia nervosa may also starve themselves for periods of time before binge eating again. Bulimia nervosa has important mental, emotional, and physical aspects that require consideration during treatment.

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